Diabetic Wound Care

What is a Diabetic Foot Ulcer?

A diabetic foot ulcer is an open sore or wound that most
commonly occurs on the bottom of the foot in approximately 15
percent of patients with diabetes. Of those who develop a
foot ulcer, six percent will be hospitalized due to infection
or other ulcer-related complication.

Diabetes is the leading cause of nontraumatic lower
extremity amputations in the United States, and approximately
14 to 24 percent of patients with diabetes who develop a foot
ulcer have an amputation. Research, however, has shown that
the development of a foot ulcer is preventable.

Who Can Get a Diabetic Foot Ulcer?

Anyone who has diabetes can develop a foot ulcer. Native
Americans, African Americans, Hispanics and older men are
more likely to develop ulcers. People who use insulin are at
a higher risk of developing a foot ulcer, as are patients
with diabetes-related kidney, eye, and heart disease. Being
overweight and using alcohol and tobacco also play a role in
the development of foot ulcers.

How do Diabetic Foot Ulcers Form?

Ulcers form due to a combination of factors, such as lack
of feeling in the foot, poor circulation, foot deformities,
irritation (such as friction or pressure), and trauma, as
well as duration of diabetes. Patients who have diabetes for
many years can develop neuropathy, a reduced or complete lack
of feeling in the feet due to nerve damage caused by elevated
blood glucose levels over time. The nerve damage often can
occur without pain and one may not even be aware of the
problem. Your podiatric physician can test feet for
neuropathy with a simple and painless tool called a
monofilament.

Vascular disease can complicate a foot ulcer, reducing the
body’s ability to heal and increasing the risk for an
infection. Elevations in blood glucose can reduce the body’s
ability to fight off a potential infection and also retard
healing.

What is the Value of Treating a Diabetic Foot Ulcer?

Once an ulcer is noticed, seek podi- atric medical care
immediately. Foot ulcers in patients with diabetes should be
treated for several reasons such as, reducing the risk of
infection and amputation, improving function and quality of
life, and reducing health care costs.

How Should a Diabetic Foot Ulcer be Treated?

The primary goal in the treatment of foot ulcers is to
obtain healing as soon as possible. The faster the healing,
the less chance for an infection.

There are several key factors in the appropriate treatment
of a diabetic foot ulcer:

Prevention of infection.

Taking the pressure off the area, called
“off-loading.”

Removing dead skin and tissue, called
“debridement.”

Applying medication or dressings to the ulcer.

Managing blood glucose and other health problems.

Not all ulcers are infected; however if your podiatric
physician diagnoses an infection, a treatment program of
antibiotics, wound care, and possibly hospitalization will be
necessary.

There are several important factors to keep an ulcer from
becoming infected:

Keep blood glucose levels under tight control.

Keep the ulcer clean and bandaged.

Cleanse the wound daily, using a wound dressing or
bandage.

Do not walk barefoot.

For optimum healing, ulcers, especially those on the
bottom of the foot, must be “off-loaded.” Patients may be
asked to wear special footgear, or a brace, specialized
castings, or use a wheelchair or crutches. These devices will
reduce the pressure and irritation to the ulcer area and help
to speed the healing process.

The science of wound care has advanced significantly over
the past ten years. The old thought of “let the air get at
it” is now known to be harmful to healing. We know that
wounds and ulcers heal faster, with a lower risk of
infection, if they are kept covered and moist. The use of
full strength betadine, peroxide, whirlpools and soaking are
not recommended, as this could lead to further
complications.

Appropriate wound management includes the use of dressings
and topically-applied medications. These range from normal
saline to advanced products, such as growth factors, ulcer
dressings, and skin substitutes that have been shown to be
highly effective in healing foot ulcers.

For a wound to heal there must be adequate circulation to
the ulcerated area. Your podiatrist can determine circulation
levels with noninvasive tests.

Controlling Blood Glucose

Tightly controlling blood glucose is of the utmost
importance dur- ing the treatment of a diabetic foot ulcer.
Working closely with a medical doctor or endocrinologist to
accomplish this will enhance healing and reduce the risk of
complications.

Surgical Options

A majority of noninfected foot ulcers are treated without
surgery; however, when this fails, surgical management may be
appropriate. Examples of surgical care to remove pressure on
the affected area include shaving or excision of bone(s) and
the correction of various deformities, such as hammertoes,
bunions, or bony “bumps.”

Healing Factors

Healing time depends on a variety of factors, such as
wound size and location, pressure on the wound from walking
or standing, swelling, circulation, blood glucose levels,
wound care, and what is being applied to the wound. Healing
may occur within weeks or require several months.

How Can a Foot Ulcer be Prevented?

The best way to treat a diabetic foot ulcer is to prevent
its development in the first place. Recommended guidelines
include seeing a podiatrist on a regular basis. He or she can
determine if you are at high risk for developing a foot ulcer
and implement strategies for prevention.

You are at high risk if you:

have neuropathy,

have poor circulation,

have a foot deformity (i.e. bunion, hammer toe),

wear inappropriate shoes,

have uncontrolled blood sugar.

Reducing additional risk factors, such as smoking,
drinking alcohol, high cholesterol, and elevated blood
glucose are important in the prevention and treatment of a
diabetic foot ulcer. Wearing the appropriate shoes and socks
will go a long way in reducing risks. Your podiatric
physician can provide guidance in selecting the proper
shoes.

Learning how to check your feet is crucial in noticing a
potential problem as early as possible. Inspect your feet
every day—especially between the toes and the sole—for cuts,
bruises, cracks, blisters, redness, ulcers, and any sign of
abnormality. Each time you visit a health care provider,
remove your shoes and socks so your feet can be examined. Any
problems that are discovered should be reported to your
podiatrist as soon as possible, no matter how “simple” it may
seem to you.

The key to successful wound healing is regular podiatric
medical care to ensure the following “gold standard” of
care:

lowering blood sugar

appropriate debridement of wounds

treating any infection

reducing friction and pressure

restoring adequate blood flow

The old saying, “an ounce of prevention is worth a pound
of cure” was never as true as it is when preventing a
diabetic foot ulcer.

Diabetes Tips From The APMA

If You Have Diabetes Already . . . DO:

Wash feet daily. Using mild soap and lukewarm water,
wash your feet in the mornings or before bed each evening.
Dry carefully with a soft towel, especially between the
toes, and dust your feet with talcum powder to wick away
moisture. If the skin is dry, use a good moisturizing cream
daily, but avoid getting it between the toes.

Inspect feet and toes daily. Check your feet every day
for cuts, bruises, sores or changes to the toenails, such as
thickening or discoloration. If age or other factors hamper
self-inspection, ask someone to help you, or use a
mirror.

Lose weight. People with diabetes are commonly
overweight, which nearly doubles the risk of
complications.

Wear thick, soft socks. Socks made of an acrylic blend
are well suited, but avoid mended socks or those with seams,
which could rub to cause blisters or other skin
injuries.

Stop smoking. Tobacco can contribute to circulatory
problems, which can be especially troublesome in patients
with diabetes.

Cut toenails straight across. Never cut into the
corners, or taper, which could trigger an ingrown toenail.
Use an emery board to gently file away sharp corners or
snags. If your nails are hard to trim, ask your podiatrist
for assistance.

Exercise. As a means to keep weight down and improve
circulation, walking is one of the best all-around exercises
for the diabetic patient. Walking is also an excellent
conditioner for your feet. Be sure to wear appropriate
athletic shoes when exercising. Ask your podiatric physician
what’s best for you.

See your podiatric physician. Regular checkups by your
podiatric physician—at least annually—are the best way to
ensure that your feet remain healthy.

Be properly measured and fitted every time you buy new
shoes. Shoes are of supreme importance to diabetes
sufferers because poorly fitted shoes are involved in as
many as half of the problems that lead to amputations.
Because foot size and shape may change over time, everyone
should have their feet measured by an experienced shoe
fitter whenever they buy a new pair of shoes.

New shoes should be comfortable at the time they’re
purchased and should not require a "break-in" period,
though it’s a good idea to wear them for short periods of
time at first. Shoes should have leather or canvas uppers,
fit both the length and width of the foot, leave room for
toes to wiggle freely, and be cushioned and sturdy.

Don’t go barefoot. Not even in your own home. Barefoot
walking outside is particularly dangerous because of the
possibility of cuts, falls, and infection. When at home,
wear slippers. Never go barefoot.

Don’t wear high heels, sandals, and shoes with pointed
toes. These types of footwear can put undue pressure on
parts of the foot and contribute to bone and joint
disorders, as well as diabetic ulcers. In addition, open
toed shoes and sandals with straps between the first two
toes should also be avoided.

Don’t drink in excess. Alcohol can contribute to
neuropathy (nerve damage) which is one of the consequences
of diabetes. Drinking can speed up the damage associated
with the disease, deaden more nerves, and increase the
possibility of overlooking a seemingly minor cut or
injury.

Don’t wear anything that is too tight around the legs.
Panty hose, panty girdles, thigh-highs or knee-highs can
constrict circulation to your legs and feet. So can men’s
dress socks if the elastic is too tight.

Never try to remove calluses, corns or warts by
yourself. Commercial, over-the-counter preparations that
remove warts or corns should be avoided because they can
burn the skin and cause irreplaceable damage to the foot of
a diabetic sufferer. Never try to cut calluses with a razor
blade or any other instrument because the risk of cutting
yourself is too high, and such wounds can often lead to more
serious ulcers and lacerations. See your podiatric physician
for assistance in these cases.

Your podiatric physician/surgeon has been trained
specifically and extensively in the diagnosis and treatment
of all manners of foot conditions. This training encompasses
all of the intricately related systems and structures of the
foot and lower leg including neurological, circulatory, skin,
and the musculoskeletal system, which includes bones, joints,
ligaments, tendons, muscles, and nerves.